It's Drugs, Alcohol
and Tobacco, Stupid!
As the new
generation of political leaders in Washington, state capitals and
city halls grapples with America's collapsing judicial systems,
rising medical costs, persistent poverty amid plenty and the defiant
federal budget deficit that looms over future generations, they
confront the same 800pound gorilla: drug, alcohol and tobacco abuse
and addiction. The sooner these leaders see how substance abuse
has fundamentally changed the nature of the pressing social and
economic problems they face, the sooner they'll deal with them effectively.
For 30 years,
we've tried to curb crime and renew our ailing court system with
tougher punishments, bigger prisons, and more cops and judges; rein
in health costs by manipulating payments to doctors and hospitals
for delivering sick care; wage war on poverty with a welfare system
that encourages dependence and drives families apart; and reduce
the deficit by cooking the federal books. Trying to reform our court
and criminal justice systems, restrain health care spending, reduce
welfare rolls, trim the deficit and nourish the American family
without confronting, front and center, substance abuse and addiction
is like trying to clean coastal waters without stopping the flow
of oil from the ruptured offshore well. It can't be done.
Congress and state legislatures have been passing laws designed
for celluloid gangsters and inmates played in classic 1930s movies
by James Cagney and Humphrey Bogart. But today's prisons are wall
to wall with drug dealers, addicts, alcohol abusers and the mentally
ill (often related to drug and alcohol abuse).
In 1960, less
than 30,000 Americans were arrested for drug offenses; by 1991,
the number had soared to more than a million. Since 1989, more individuals
have been incarcerated for drug offenses than for all violent crimes-and
most violent crime is committed by drug and alcohol abusers. Alcohol
and drug abuse are implicated in threequarters of all spouse
abuse, rapes, child molestations, suicides and homicides.
In 1994, the
number of Americans in prison broke the one million barrier and,
on its current trajectory, will double soon after the turn of the
century. The United States is second only to Russia in the rate
of citizens it imprisons: 519 per 100,000, compared to 558 in Russia,
368 in thirdplace South Africa, 116 in Canada and 36 in Japan.
and parole are sick jokes in most American cities. With so many
parolees needing drug treatment and aftercare as essential first
steps to rehabilitation, they demand far more monitoring than their
drugfree predecessors of a generation ago. Yet in Los Angeles,
for example, probation officers must handle as many as 1,000 cases
at a time. With most offenders committing drug or alcoholrelated
crimes, it's no wonder so many of them go right back to jail: 80
percent of prisoners have prior convictions and more than 60 percent
have served time before.
turned the private security industry from a less than fourbillioncollar
weakling in 1970 into a 70billiondollar behemoth in
1994, as office buildings and homes install sophisticated protection
systems and commercial properties post guards around the clock.
prosecutors are demoralized as they juggle caseloads more than double
the recommended maximums. The rush of drug related criminal cases
has created intolerable delays for civil litigants: four years in
Newark, five in Philadelphia, up to ten in Cook County, Illinois.
In many jurisdictions, divorce and separation cases languish for
years, as splitting parents and their children struggle to survive
in a limbo of nasty uncertainty.
and civility of urban life have been shattered by alcohol and drugrelated
crimes. Children kill children and innocents are downed by random
gunfire from warring drug gangs. Elementary and high school students
are required to pass through metal detectors in order to check for
weapons, the deadly companions of the drug trade, and teachers are
locked in classrooms for their own protection.
can no longer buy out of the mess. Individuals walking Wisconsin
Avenue in Washington D.C.'s Georgetown, Madison Avenue in New York,
Newbury Street in Boston and the Miracle Mile in Chicago are accosted
by angry, aggressive panhandlers, many seeking money for their next
fix. The ugly scrawls of graffiti on city buildings mark not only
the arrival of spray paint, but also the widespread abuse of drugs
abuse is an equal opportunity killer, snaring addicts in every social
and economic class. Store owners lock their doors during daytime
business hours in fear of robbery by alcohol and drugcrazed
criminals. Office managers bolt computers to desks to prevent theft.
Customers and employees warily read headlines about murders and
assaults, often committed under the influence of alcohol and drugs,
that have torn apart the comfortable routines where America works,
eats and shops- post offices, fastfood restaurants, banks
and supermarkets. Twothirds of illegal drug users are employed,
adding an element of Russian roulette to going to work each day.
In 1995, drugs,
alcohol and tobacco will trigger some $200 billion in health care
rooms are piled high with the debris of drug use on city streets.
From Boston to Baton Rouge, hospitals teem with the victims of gunshot
wounds and other violence caused by alcohol abusers, drug addicts
and dealers, and of a variety of medical conditions, such as cancer,
emphysema and cardiac arrest, caused by alcohol, tobacco, cocaine
and other drugs.
AIDS and tuberculosis
spread rapidly and not just among intravenous drug users and crack
addicts. Beyond sharing dirty needles and trading sex for drugs,
individuals high on beer, other alcohol and pot are far more likely
to have sex and to have it without a condom.
The more than
500,000 newborns exposed each year to drugs and/or alcohol during
pregnancy is a slaughter of innocents of biblical proportions. Crack
babies, a rarity a decade ago, crowd $2,000aday neonatal wards.
Many die. Each survivor can cost one million dollars to bring to
adulthood. Fetal alcohol syndrome is a top cause of birth defects.
prenatal care is available, women on drugs and alcohol are not likely
to take advantage of it. Those who do seek help must often wait
in line for scarce treatment slots. Mothers abusing drugs during
pregnancy account for most of the $3 billion that Medicaid spent
in 1994 on inpatient hospital care for illness and injury due to
in History's Most Affluent Society
Drugs have changed the nature of poverty in America. Nowhere is
this more striking than in the persistent problem of welfare dependency.
At least 20
percent of Chicago and Maryland's Montgomery County adults on welfare
have drug problems. And that may be low compared to other urban
areas. Many of the million teenagers who get pregnant each year
are high on alcohol or drugs at the time they conceive, and one
of the surest ways to get locked in poverty is to become an unwed
mother before graduating from high school. At least half the homeless
men and women-some say 80 to 90 percent-are alcohol and drug abusers.
electorate is hellbent on putting welfare mothers to work.
But all the financial sticks and carrots and all the job training
in the world will do precious little to make employable the hundreds
of thousands of welfare recipients who are drug and alcohol abusers.
For too long, reformers have had their heads in the sand about this
unpleasant reality. Liberals fear that acknowledging the extent
of alcohol and drug use among welfare recipients will incite even
more punitive reactions than those currently in fashion. Conservatives
don't want to face up to the cost of treatment.
denial ensures failure. Any reform that will move individuals from
welfare to work must provide funds to treat drug and alcohol abuse.
Supplemental Security Income, the welfare program that provides
monthly checks to blind, disabled and poor adults, reveals the grim
and expensive consequence of the alternative. Of 90,000 individuals
receiving SSI primarily because of substance abuse, fewer than ten
percent are in treatment. Not surprisingly, the U.S. Department
of Health and Human Services found that thousands of these addicts
and alcoholics receive benefits until they die.
have added a vicious strain of intractability to urban poverty.
Drugs are the greatest threat to family stability, decent housing,
public schools and even minimal social amenities. Widespread drug
use derails the emotional, social and intellectual development not
only of the children who abuse them, but also of their peers and
neighbors who must grapple with the violent consequences of rampant
drugs in housing projects and schools. It becomes difficult-sometimes
impossible-for children in this sordid environment to acquire the
basic educational and social skills they need to get out of poverty.
In fiscal 1995, tobacco, alcohol and drug abuse will account for
at least $77.6 billion in entitlement expenditures, an amount equivalent
to 40 percent of the 1995 federal budget deficit.
Of that amount,
$66.4 billion are costs to health and disability programs, such
as Medicare, Medicaid and veterans' health and disability. Cigarette
smoking is by far the biggest culprit. Twothirds of the $66.4
billion-$44 billion-is attributable to tobacco. Alcohol accounts
for 18 percent and drugs for 16 percent.
abuse takes its biggest slice from the veterans' health care program.
Nearly 30 percent of the dollars spent on veterans' health is due
to substance abuse, more than half of that as a result of alcohol
and drug abuse. Welfare payments to illegal drug addicts and alcoholics
draw the rhetorical fire of legislators. But American taxpayers
fork over $4.6 billion a year to individuals on Social Security
disability as a result of smoking cigarettes.
Of the $77.6
billion, the remaining $11.2 billion is spent on welfare, food stamp
and Supplemental Security Income recipients who regularly use alcohol
and drugs and are unlikely to get off the rolls without treatment
attack by the President and the Congress on entitlement programs-from
Medicare and veterans' health and disability to Medicaid and welfare-has
to confront substance abuse and addiction. That means a significant
investment in prevention and treatment of all abuse. Simply removing
individuals who abuse alcohol and drugs from disability, welfare
and health care programs will only shift costs to the states, cities
and counties, which will then have to deal with the resulting illness,
hunger, homelessness and crime. Indeed, a wholesale denial of benefits
to alcoholics and drug addicts without providing treatment and aftercare
will push up the crime rate and scatter thousands more homeless
individuals on America's streets.
Anything We Can Do?
We can begin by ending our national and personal denial of the tough
truth denominator of the nation's hot buttons- crime and violence,
health care costs, welfare reform and the budget deficit-is substance
abuse. Our denial keeps our sights on the wrong targets. Indeed,
92 percent of federal health entitlement program costs attributable
to substance abuse is spent to treat the consequences of tobacco,
alcohol and drugs; only eight percent is spent to treat the tobacco,
alcohol or drug dependence itself.
and citizens focus on the top killers: heart disease (720,000 deaths
in 1990), cancer (505,000), stroke (144,000), accidents (92,000),
emphysema (87,000), pneumonia and influenza (80,000), diabetes (48,000),
suicide (31,000), chronic liver disease and cirrhosis (26,000),
and AIDS (25,000). But they give scant attention to the causes of
these killers, which, according to a 1993 Journal of the American
Medical Association study, include tobacco (435,000 deaths), alcohol
(100,000) and illicit drug use (20,000).
with the consequences and neglect of the causes is not limited to
health care. We pump billions into combating crime-cops, courts,
prisons and punishment-and pennies into preventing the drug and
alcohol abuse and addiction that spawn so much criminal activity.
We pour resources into shoveling up city slums- rebuilding gutted
housing, putting more cops on unsafe streets and barbed wire around
housing projects-and little into curbing drug and alcohol abuse.
And we often use our hefty budgetcutting axes to chop down
prevention and treatment programs, which are most likely to reduce
the deficit over the long run
with the causes requires upfront investments-the kind that
corporations make every day to produce longterm results for
their stockholders, the kind that parents make to give their children
the best education they can get. It also requires that we scrub
the stigma off drug and alcohol abuse and devote the kind of energy
and resources to research on addiction and its prevention that we
have committed to cancer and heart disease. And it requires common
Here are a
few starter suggestions:
federal funds to state and federal prison systems only if they
provide drug and alcohol treatment and aftercare for all inmates
who need such care.
of acrosstheboard mandatory sentences, keep inmates
in jails, boot camps or halfway houses until they demonstrate
at least one year of sobriety after treatment.
drug and alcohol addicts to go regularly to treatment and aftercare,
like Alcoholics Anonymous, while on parole or probation.
federal funds for police only to cities that agree to enforce
drug laws throughout their jurisdictions. End acceptance of
drug bazaars in Harlem, southeast Washington, D.C, and south-central
Los Angeles, which would not be tolerated on the streets of
New York's Upper East Side, Georgetown or Beverly Hills.
judges with lots of drug cases to employ public health professionals,
just as they hire economists to assist with antitrust
cases. Drug cases present far more complex human and medical
problems than the economic issues posed by commercial litigation.
higher Medicare premiums to individuals who smoke.
welfare payments to drug addicts and alcoholics who refuse to
seek treatment and pursue aftercare. As employers and health
professionals know, addicts from CEOs to chambermaids need lots
of carrots and sticks, including the threat of losing their
jobs and incomes, to get the monkey off their backs.
inmates, parolees and welfare recipients with a history of drug
or alcohol abuse to random tests and fund the treatment they
need. Conservatives who preach an end to recidivism and welfare
dependency must recognize that reincarceration and removal from
the welfare rolls for those who test positive is a cruel catch22
unless treatment is available. Liberals must recognize that
getting off drugs is the only chance these individuals (and
their babies) have to enjoy their civil rights.
parents who abuse their children by their own drug and alcohol
abuse and place those children in decent orphanages and foster
care until the parents go into treatment and shape up.
only a few suggestions. The overriding point is that addiction and
abuse-involving heroin, cocaine, hallucinogens, amphetamines, inhalants,
marijuana, alcohol and tobacco-have fundamentally changed the nature
of America's pressing social and economic challenges, and we must
rethink how we address them. If a mainstream disease like diabetes
or cancer affected as many individuals and families as drug, alcohol
and tobacco abuse and addiction do, this nation would mount an effort
on the scale of the Manhattan Project to deal with it.
© 1996, The National
Center on Addiction & Substance Abuse at Columbia University